HomeMy WebLinkAboutMiscellaneous - 255 SALEM STREET 4/30/20180
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AUHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO DASFITTING
(Print or Type)
NORTH ANDOVER , Maas. Date tg�jL
Building Permit #�
Locatlon 2 3 ,,S' �' y}- i�e
New ❑
aUr!-80MT,
•ASEMEHT
IST
FLOOR
2MO,FLOOR
SAO FLOOR
4TH FLOOR
sTH FLOOR
1sTH FLOOR
7TH FLOOR
4THPLOOR
Owner'a
Name 'r_ 19
Renovation L Replacement ❑ Plans SubmMed:. Yes ❑ No
El
Installing Company Name_ Z,? �%'c
Address
Check one:
�I Corp.
d Partnerahip
❑ Fir /C
� o.
Business Telephone m
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
1 have a current IlabllRy Insurance policy or its substantial equivalent. ' Yeac❑ one
If you have checked yea, please Indicate the .
type coverage by checking the appropriate box.
A itabplty insurance policy ❑ Other type of Indemnity ❑ n,...,, n
Certificate
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this
Permit application waives this requirement.
Check one:
nature of towner or Owners Agent Owner ❑ Agent ❑
i hereby certify that all of the details and Information 1 have submitted (or entered) In above appllcallon are true and accurate to the best of my
knorvledpe and that all plumbing work and Installations performed under the permit Issued for this appllcatlcon will be compliance with all
pertinent provisions of the Massachusetts State Gas Code and grapter 142 of Uwe oar wel LAws_
Tof Lkense:
Title Plumber
Oaslitter %na ire o nae um er or as er
9
gtyRgwn Master ❑ Journeyman License Number
ArPnOVED (OFFICE USE ONLY)
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Installing Company Name_ Z,? �%'c
Address
Check one:
�I Corp.
d Partnerahip
❑ Fir /C
� o.
Business Telephone m
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
1 have a current IlabllRy Insurance policy or its substantial equivalent. ' Yeac❑ one
If you have checked yea, please Indicate the .
type coverage by checking the appropriate box.
A itabplty insurance policy ❑ Other type of Indemnity ❑ n,...,, n
Certificate
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this
Permit application waives this requirement.
Check one:
nature of towner or Owners Agent Owner ❑ Agent ❑
i hereby certify that all of the details and Information 1 have submitted (or entered) In above appllcallon are true and accurate to the best of my
knorvledpe and that all plumbing work and Installations performed under the permit Issued for this appllcatlcon will be compliance with all
pertinent provisions of the Massachusetts State Gas Code and grapter 142 of Uwe oar wel LAws_
Tof Lkense:
Title Plumber
Oaslitter %na ire o nae um er or as er
9
gtyRgwn Master ❑ Journeyman License Number
ArPnOVED (OFFICE USE ONLY)
a...-.�-y'.i.- � ." .-..'.�.-,may ,_, , .f F_F'. 4c �_' ;..k'� �.f'... • i
t
Date.
............
ECEiVEp p
YEN ,.
H°RTN QPRTgVY OF NORTH ANDOVER
%
3�Ory c rT x.49? ...,,.J
o PERMIT FOR GAS INSTALLATION
* a a *No. Andovqr Collector
�
QogATE o�APpy4y 9SSAC HUSo-
This certifies that .{f � X r A.,.— !� � ................ �
has permission for gas installation .tl : ' r ...... ........
in the buildings of ....... ............................... .
at ... ....... '!.t ....r.. ... . ,North Andover, Mass
Fee. . ? ::.. Lic. No. ........... ...... .
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File - . '.